Updated AUC for Stable Ischemic Heart Disease Seek to Match ‘Appropriateness’ to Current Practice

(UPDATED) Nearly a decade after appropriate use criteria (AUC) first emerged for coronary revascularization, the latest chapter is complete—a document dedicated solely to the treatment of patients with stable ischemic heart disease (SIHD).

Published online today in the Journal of the American College of Cardiology, the SIHD-focused AUC complement the standards set forth for acute coronary syndromes released last December. As in that document, here the terms “may be appropriate” and “rarely appropriate” now officially replace the “uncertain” and “inappropriate” phrasing seen in the 2009 and 2012 AUC iterations. There is also inclusion of physiologic assessment and a section devoted to the role of patient preference, as in the 2016 ACS-focused AUC.

“As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with high symptom burden, high-risk features, high coronary disease burden, and in patients receiving antianginal therapy are deemed appropriate,” note writing group chair Manesh R. Patel, MD (Duke University Medical Center, Durham, NC), and colleagues.

To TCTMD, Patel said he hopes the update means “we’re in the adolescence-to-maturing stage of the AUC now,” 12 years after the process to create them began in 2005. With input from many societies and individual physicians across specialties, he said, the AUC are meant to be “broad representation of what clinical practice is,” with the recognition that it’s impossible to capture every aspect of cardiovascular revascularization. Moving forward, to keep the criteria current, the tentative plan is that sections of the document can be updated yearly to reflect changes in the evidence base, Patel reported.

What with the timing of the document, there is sure to be much discussion at the upcoming American College of Cardiology meeting, he predicted.

For the SIHD AUC, new clinical scenarios reflecting real-word practice were added, namely the appropriateness of revascularization before kidney transplantation or transcatheter valve therapy. There is added emphasis on how to weigh the presence or absence of diabetes. Patients are stratified based on whether they are asymptomatic or have ischemic symptoms, and Canadian Cardiovascular Society grading is no longer used to assess symptom severity.

Another key change lies in what constitutes antianginal therapy. Prior AUC mandated “maximal anti-ischemic medical therapy” consisting of two or more antianginal medications to reduce symptoms. That standard has “been replaced by a step-wise use of antianginals,” a press release explains. “This starts ideally with a guideline-directed beta-blocker as first-line therapy, with other antianginals used to escalate therapy as clinically necessary.” That gradual approach to advancing medical therapy, it notes, is now “integrated” with the determination of whether PCI or CABG is considered appropriate.

Commenting on the new AUC for TCTMD, Emmanouil S. Brilakis, MD, PhD (Minneapolis Heart Institute, Minneapolis, MN), cited the omission of chronic total occlusions (CTOs) in the standards as a notable development. “In the previous version, there were separate recommendations for CTOs, [with] CTOs actually downgraded to a certain extent as compared to non-CTO lesions,” he said.

This division no longer exists, he pointed out. “I think this reflects the current reality that you can recanalize those lesions with pretty high success.” Nor is there any “breakdown for calcified lesions or for other anatomically complex subsets,” Brilakis added. “That in a way is good because it lets the operator decide if the complexity is something he can tackle or not.”

For Brilakis, the advice related to revascularization in the setting of transplantation is “a little more speculative, a little more pushing the boundary, because there is very little actual data regarding the appropriateness of revascularization and the outcomes in this patient group,” Brilakis noted. That said, having some sort of guidance is still helpful, he added.

AUC Not the ‘Final Arbitrator’ of Individual Cases

“The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision-making,” Patel et al say, reporting that further advice on how to “blend” the AUC ratings into the process of shared decision-making alongside patients will come out as part of an expert consensus document now being developed.

What the AUC should not do is serve as “the final arbitrator of specific individual cases,” the writing group stresses. “The [American College of Cardiology] and its collaborators believe that an ongoing review of one’s practice using these criteria will help guide more effective, efficient, and equitable allocation of healthcare resources, and ultimately, better patient outcomes.”

The updated SIHD AUC represent a step in the right direction, Brilakis agreed, noting that the scorecards provided by the National Cardiovascular Data Registry and other big-picture information on appropriateness are where the AUC most come in handy. “But what everyone should remember is every patient is different,” he said, adding that it’s impossible for one document to cover all scenarios. Sometimes a “may be appropriate” or “rarely appropriate” choice may be “the best therapy for a specific patient,” Brilakis observed, emphasizing that AUC should not be used to deny coverage in individual cases.

Taking on the issue of tying reimbursement to perceived procedure appropriateness, which most strikingly came to the fore in New York State, Patel et al stress that “under no circumstances should the AUC be used to adjudicate or determine payment for individual patients.”

Also important, Patel noted to TCTMD, is that the AUC remain freely available. “These data and these types of documents should be what I call ‘freeware.’ They should be information that’s available to all hospitals and practices, that they can put into their own [electronic health records] and information systems, so that they can in real time identify how to care for their patients,” he commented.